| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,734 |
10,656 |
$517K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,252 |
1,094 |
$393K |
| D0120 |
Periodic oral evaluation - established patient |
5,452 |
5,412 |
$378K |
| D1310 |
|
7,068 |
7,020 |
$305K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,927 |
1,947 |
$266K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,199 |
10,127 |
$219K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,006 |
2,986 |
$203K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,571 |
641 |
$154K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,567 |
3,089 |
$144K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,501 |
1,271 |
$143K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,678 |
1,667 |
$115K |
| D1351 |
Sealant - per tooth |
3,090 |
1,133 |
$115K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,413 |
7,515 |
$112K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,905 |
1,181 |
$104K |
| D0603 |
|
6,214 |
6,173 |
$88K |
| D0272 |
Bitewings - two radiographic images |
6,221 |
6,177 |
$72K |
| D1510 |
|
158 |
126 |
$32K |
| D0350 |
|
2,674 |
1,448 |
$26K |
| D9430 |
|
810 |
786 |
$26K |
| D9993 |
|
733 |
729 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,268 |
1,236 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
370 |
370 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
125 |
99 |
$10K |
| D0330 |
Panoramic radiographic image |
386 |
386 |
$10K |
| D2330 |
|
126 |
86 |
$10K |
| D0602 |
|
642 |
642 |
$9K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
20 |
12 |
$6K |
| D0274 |
Bitewings - four radiographic images |
252 |
252 |
$5K |
| D9222 |
|
12 |
12 |
$1K |
| D9610 |
|
23 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$409.00 |
| D0270 |
|
12 |
12 |
$60.00 |
| D1330 |
|
186 |
186 |
$0.00 |